factors and management

Question 1

What local factors contribute to plaque stagnation, accumulation and perio (anatomical and acquired)

Answer 1

Occlusion (traumatic overbites causing trauma to soft tissues), root grooves (hard to clean), furcations (hard to clean), enamel pearls and cervical enamel projections (stagnation), recession, premature contacts (causing localised bone loss), overcrowding, high labial frenum (hard to clean)

-Overhanging restorations, sub gingival restorations (encroachment of biological width), inadequate contact points, removable appliances, orthodontic appliances, open contacts, root fractures (accumulation and bone loss), root resorption (accumulation and bone loss), orthodoxy treatment causing bone resorption

Question 2

What is biological width and its relevance to restorations. Rough length

Answer 2

= The distance between the bottom of the gingival sulcus to the alveolar crest (connective tissue and junctional epithelium ~2mm)
-it is essential to consider it for maintaining healthy gingiva when doing restorations as enroaching the biological width can cause inflammation
-It is 3mm. so must keep restoration 3mm clear of alveolar crest

Question 3

Management of furcations

Answer 3

-calculus/ plaque removal, PMPR, clean with teepee, single tufted brush,
-surgical: furcationplasty, tunnel preparation, RSI with flap surgery for access, guided tissue regeneration, root resection

Question 4

Management of traumatic incisal relationships. Why it can contribute to perio

Answer 4

-large class II or class III can cause incisors to damage palatal and labial tissues. class II div II can cause shearing trauma
-management: single tufted brush, soft splint to cushion the impact, orthodontic surgery to reposition occlusion, provision of posterior support, anterior restorations to provide occlusal steps, overlay denture to reduce contact of anterior teeth on soft tissues

Question 5

List potential systemic risk factors for perio

Answer 5

Smoking, diabetes, genetics, age, socioeconomic status, medications, hormones, pregnancy, stress, systemic disease (eg. down’s), poor diet, obesity, alcohol

Question 6

Why smoking contributes to perio. How more likely are you to have perio if you smoke

Answer 6

-Smokers 4 times as likely to have it than non-smokers.
-Due to changes in immune response. Impaired Neutrophil, lymphocyte, fibroblasts, immunoglobin, cytokines production and function and levels so less effective immune defenses.
-Reducing blood flow to gingiva so reduced oxygen and nutrients to cells and immune cells to area. Altered microflora, more pathogenic as more anaerobic conditions due to impaired vasculature.
-Increased levels of cytokines causes a shift in Pro inflammatory conditions and increased inflammation

Question 7

How hormones in puberty and pregnancy can affect perio disease

Answer 7

Elevated oestrogen and progesterone increases capillary permeability/ vasodilation/ increased blood flow. Also increases inflammatory and immune responses which aggravates periodontal conditions. Only causes transient gingivitis, so no long-term damage.

Question 8

What gingival conditions can occur during pregnancy

Answer 8

Pregnancy has increased risk of gingival hyperplasia (benign overgrowths) and pyogenic granuloma (pregnancy tumours) and gingivitis

Question 9

How stress can lead to perio disease

Answer 9

Could be due to change in behaviours (poorer OH, increased smoking and alcohol). Or physiological changes – reduces leukocyte function, altered cytokines, pro-inflammatory conditions, salivary changes

Question 10

What 3 drug categories and names can cause gingival overgrowths

Answer 10

-Calcium channel blockers – Nifedipine, amlodipine
-Immunosuppressants – Cyclosporin
-immunosupressant for organ rejection. Stimulates fibroblasts so more collagen
– Phenytoin - anti-convulsant for epilepsy. Overproduction of collagen

Question 11

drug-induced gingival overgrowths: clinical features, management, cause

Answer 11

-Clinical features: diffuse enlargement, vascular lobulated overgrowth. inflammation, swelling, BOP, overgrowth starts at interdental papillae which continues to grow and coalesce. Then starts to affect attached gingiva. Compromises aesthetics and OH.
-Management: Recommend single tufted brush. OHI, debridement. Liase with GP so consider changing meds. surgical excision (gingivectomy) and recontouring (gingivoplasty).
-Causes: Due to proliferation of fibroblasts and increased collagen contact, creating fibrous tissue overgrowths. Highly vascularized tissue with increased inflammatory cells.

Question 12

How diabetes causes perio. What molecule is the main cause

Answer 12

-Perio and diabetes both chronic inflammatory conditions so linked by a bidirectional relationship.
-Increased glycosylation of proteins in uncontrolled diabetes creates AGEs (advanced glycation end products)
-AGE interacts with RAGE which promotes cytokines (inflammation and local damage), microvascular damage (affecting leukocyte/ nutrient delivery), reduced collagen turnover (reduced periodontal healing), increases collegenase, PMN dysfunction, tissue breakdown
-Impacts immune system so more risk of infection
-AGEs therefore responsible for increasing periodontal disease.

-Anterior more inflamed as diabetes obliterates arteries which worsens perio disease

Question 13

What marker is used to assess glycemic control.

Answer 13

measuring HbA1c in blood. this is a glycated haemoglobin
-The measurement of plasma glucose

Question 14

type 1 and 2 diabetes

Answer 14

Elevated glucose. Increased risk if poor glycemic control
-type 1= autoimmune. body attacks beta pancreatic cells so don’t produce enough insulin so cannot store glucose as glycogen
-type 2= metabolic. insulin becomes de-sensitised so body becomes more resistant to it and blood glucose cannot be controlled

Question 15

Role of dentists when it comes to diabetes

Answer 15

-be aware of bidirectional links of perio and diabetes
-educate patient of links
-regularly update MH of diabetes and level of control
- be aware of HbA1c for measuring plasma glucose
-regular monitoring of these patients
-provide preventative care
-Consider assessing risk of diabetes when suspected and liaising with the medical doctor when there is evidence of increased diabetes risk
-regular review and recall

Ask if it is stable, what was their most recent glucose level, have they eaten, what meds they are on

Question 16

What is papillon-lefevre syndrome and how it can be linked with perio

Answer 16

mutation in cathepsin C gene, causing impairment in immune response to bacteria. Characterized by lesions on hands and feet, severe generalized periodontal disease, and early loss of primary and permanent teeth

Question 17

What is ehlers-danlos syndrome and how it is linked with perio disease

Answer 17

defective collagen synthesis. Excessive joint mobility, increased skin fragility, skin extensibility, fragile tissues.
-Type VIII associated with periodontitis. Increased trauma risk in periodontal treatment so caution required to not damage the tissues

Question 18

What is Down’s syndrome and how it is linked with perio. what chromosome is affected

Answer 18

trisomy chromosome 21 (additional copy)
-Increased prevalence and severity of periodontitis. Due to alterations in immune response, neutrophil chemotaxis, phagocytosis.
-Local factors include restricted access for cleaning, overcrowding, class III, lack of lip seal and mouth breathing causing reduced saliva, high frenal attachments, reduced compliance to OH, lack of dexterity, lack of motivation, shorter roots

Question 19

How leukaemia linked with perio disease

Answer 19

malignant neoplasm of the bone marrow, causing increased proliferation of white blood cells and their precursors. Reduces the amount of platelets, often causing thrombocytopaenia and gingival bleeding. Gingival swelling due to infiltration of leukaemic cells. Also oral petechiae and oral ulceration

Question 20

How neutropenia linked with perio

Answer 20

reduced neutrophils, increasing risk of infection. Congenital or acquired.
-Manifestations included ulceration/ necrosis of marginal gingiva, gingival bleeding, generalized severe periodontal disease

Question 21

How Chidiak-Higashi syndrome and Leukocyte adhesion-deficiency syndrome linked with perio

Answer 21

Chidiak-Higashi syndrome: impaired neutrophil function. Severe perio even at young age, early exfoliation of primary and permanent

Leukocyte adhesion-deficiency syndrome: impaired wound healing, prone to severe infection

Question 22

What is hypophosphatasia and why it is linked with oral abnormality

Answer 22

error in metabolism. Mutation in gene encoding alkaline phosphatase enzyme important for mineralization of bone and teeth.
-Skeletal manifestations (short limbs, bowed legs), early loss of teeth, abnormalities of tooth formation (enlarged pulps, abnormalities in morphology, hypoplasia)

Question 23

List systemic diseases that perio may cause

Answer 23

diabetes, atherosclerosis, obesity, rheumatoid arthritis, osteoporosis, chronic kidney disease, COPD colon or pancreatic cancer, IBD, adverse pregnancy outcomes (low birth weight)

Question 24

How perio can cause systemic disease

Answer 24

Highly vascular periodontium means subgingival bacteria, bacterial products and pro-inflammatory molecules can enter the blood and affect distal sites and systems, potentially causing systemic diseases = metastatic infection, inflammation, injury. Trigger immune responses elsewhere.

Question 25

How perio can cause diabetes

Answer 25

Pathogens and cytokines etc. entering the circulation reduces pancreatic Beta cell function, cause apoptosis, causes insulin resistance, elevated HbA1c levels, exacerbating the diabetic state
-perio therapy has shown to be very effective at reducing HBA1c levels

Question 26

How perio can be linked with atherosclerosis

Answer 26

P gingivalis, F nucleatum, A actinomycetemcomitans found in atherosclerotic plaques. These pathogens enter the circulation and directly or indirectly induce inflammation

Question 27

Explain the BSP management pathways that is taken for perio patients (step 1-4)

Answer 27

-Step 1 (OHI, supra PMPR etc.)
-Re-evaluate and those not responding continue with stage 1, and those engaging go to…
-Step 2 (sub PMPR)
-Re-evaluate and those unstable go to step 3, those stable go to step 4
-Step 3 (manage non-responding sites)
-Step 4 (maintenance)

Question 28

What is involved in step 1 perio pathway and the aims

Answer 28

-Educate about disease, tailored OHI, smoking, remove plaque retentive factors (eg. Overhanging restoration), supragingival PMPR, diabetes control,
-aims= biofilm control, remove plaque retentive factors, address risk factors, reduce gingival inflammation, deliver education, improve patient compliance with advice, ensure patient takes ownership of their role in disease management, improve OH and habits
-Review within 3 months.

Question 29

How to assess patient engagement. Who stays with step 1 therapy, who moves onto step 2

Answer 29

-Engaging patient= favourable improvement in OH. ≥50% improvement in plaque and BOP scores. OR plaque score ≤20% and BOP ≤30%. OR patient has met targets in care plan made by healthcare practitioner.

-Non-engaging= insufficient improvement in OH. <50% improvement in plaque and BOP scores. OR >20% plaque level and >30% BOP. OR patient wants a palliative approach to perio care

Question 30

What is involved in step 2 perio therapy. When it needs reviewing and what is involved

Answer 30

-Subgingival PMPR, reinforcing OH, behaviour change and risk factor control, use of adjunctive systemic antimicrobials (mouthwashes)
-6 week review= assess healing of soft tissues, reinforcing OHI, reassess motivation
-3 month review= assessing stability of disease. full perio re-evaluation of gingival health, OH, risk factors, motivation, compliance. OHI, plaque score. Further sub PMPR. PPDs, BOP, CAL, mobility, furcation, recession
-may need further step 2 or referral

Question 31

When should subgingival PMPR considered

Answer 31

if active disease diagnosed, for motivated patients complying with advice, patient consents, for pockets >5mm or 4mm with BOP. Usually a quadrant by quadrant approach

Question 32

After step 2, how to assess stability of perio disease and who should go to step 3 and step 4

Answer 32

step 3 for those with active unstable disease
step 4 for those who’s treatment has been successful. stable disease or in remission

stable: BOP <10%. PPD ≤4mm. No BOP at 4mm sites
In remission: BOP≥ 10%. PPD ≤4mm. No BOP at 4mm sites
Unstable: PPD ≥5mm or PPD≥4mm with BOP

Question 33

If a patient has undergone previous non-surgical perio therapy what pocket depths can they have without BOP to be classified as stable or in remission

Answer 33

5-6mm pockets with no BOP

Question 34

What step 3 involves

Answer 34

-for those not responding well to step 2
=management of non-responding sites
-further treatment planning which involves further non-surgical perio therapy (OHI etc.), sub PMPR, adjunctive, possible referral to specialist, perio surgery
-6 week soft tissue review then 3 month review

Question 35

What step 4 perio therapy involves. aims

Answer 35

-it is the maintenance phase for those responding well to step 2 sub PMPR (stable or in remission)
-reinforce OH, risk factor control, behaviour change, regular PMPR, adjunctive, monitoring motivation and perio/ systemic health
-long-term ongoing care, so patient needs to invest in regular maintenance for life
-aim to prevent relapse, maintain stability, initiate further treatment if progression is detected

Question 36

When to refer a perio patient to a specialist

Answer 36

-usually after step 3
-when no response to previous optimally completed treatment, deteriorating perio condition after non-surgical management, rapidly progressing perio, medical history that affects clinical management (history of head and neck radiotherapy or bisphosphonate therapy, immunocompromised, bleeding disorder, drug interactions, systemic disease affecting perio (unstable diabetes), complicating anatomical factors affecting prognosis, concurrent mucogingival disease (eg. Pemphigus)

Question 37

2 contraindications for perio surgery

Answer 37

-not normally undertaken following a single phase of non-surgical care - The outcome of the first phase is reviewed and non-surgical care repeated for non-responding sites in engaging patients.
-In non-engaging patients - it will likely fail. attempts should be made to engage patient in behaviour change and establishing optimal levels of OH

Question 38

The aims of supportive periodontal care. what it involves. What is the recall interval

Answer 38

-it is professional therapeutic measures that support a patient’s own efforts to control periodontal infections and avoid re-infections
-aims of reducing PPDs, BOP, CAL, plaque score, tooth loss inflammation
-involves: risk factor assessment, OH assessment (eg. Plaque index), sub and supra gingival scaling, RSI + LA of deep sites, indices, radiographs to monitor disease. It can be provided in general dental practice with same outcomes as specialist clinic
-recall frequency 2-4 months

Question 39

What is calculus

Answer 39

mineralized bacterial plaque. Dental pellicle can also calcify. Secondary cause of periodontitis. Calcium phosphate crystals.

Question 40

Aims of sub PMPR

Answer 40

it is not 100% necessary to remove it all, as long as it is smooth to disrupt and reduce the biofilm and not make it retentive, and so that PDL can reattach
-removing calculus as it is a plaque retentive factor
-conserve tooth structure
-resolve inflammation
-creating a biologically acceptable root surface

Question 41

What BOP, tooth loss, systemic factors and PPDs are considered high risk and low risk at perio risk assessment

Answer 41

BOP<10% low risk
BOP >25 % high risk
<4 tooth low is low risk
>8 tooth loss high risk
diabetes, genetics high risk
PPD >5mm high risk
Furcations high risk

Question 42

What is considered low, moderate and high risk for smoking

Answer 42

Non-smokers/ former smokers for <5y=low risk
Occasional smokers (<10 a day)= moderate risk
Heavy smokers (one pack a day)= high risk

Question 43

smoking cessation options

Answer 43

Nicotine replacement therapy (patches, sprays)
Behavioural counselling
Family and friend support
Vaping

Question 44

What is VBA for smoking cessation, what it involves

Answer 44

-very Brief advice on smoking. Should take 30s
1. Ask about their status
2. Advise how to quit (with combo of meds and specialist support)
3. Act: build confidence, give info, refer to local stop smoking service
don’t lecture about why smoking is bad

Question 45

What oral conditions smoking can increase the risks of

Answer 45

Oral neoplasia, cancer, leukoplakia, periodontitis, ANUG, candida, melanosis, caries (less evidence), dry sockets, staining, halitosis, tooth loss, peri-implantitis

impaired vasculature, immune impairment, affects microbiota, wound healing impairment,

Question 46

why vapes may be a good alternative for smokers

Answer 46

-Heats liquid containing nicotine to form a vapor which is inhaled rather than smoke. Doesn’t produce tobacco, or produce tar or CO
-Vaping only poses a small fraction of the risks of smoking, so good option for those wanting to quite smoking, but don’t recommend to non-smokers
-Increases quitting rates compared to NRT

Question 47

Explain the following brushing techniques: horizontal scrub, bass technique, modified stilman, and charter’s technique

Answer 47

-Horizontal scrub= back and forth motion. Simplest method, not as effective
-Bass technique= 45 degree angle of bristles at gumline, back and forth vibrating motion, all 3 tooth surfaces, vertical orientation behind anteriors
-Modified Stillman= involves a rolling stroke coronally to minimise gingival trauma & increase plaque removal
-Charters’ =circular motions. Aids cleaning of abutment teeth, under gingival border of bridges, ortho appliances

Question 48

Advantages and disadvantages of bass technique

Answer 48

Provides good gingival stimulation
Easy to learn
BUT over brushing can cause gingival injury
can be time consuming
dexterity required may be too high for come patients
vibratory aspect may be ineffective for biofilm removal at gingival margin

Question 49

Negative outcomes of PMPR

Answer 49

-Gingival recession (due to reduced inflammation. although this is also a positive outcome, resulting in a shallower pocket)
-Root sensitivity (due to recession, cementum removal, calculus removal)
-Aesthetic concerns – black triangles between teeth

Question 50

Healing stages after sub PMPR

Answer 50

-Within a few hours: acute inflammatory reaction in the pocket wall due to trauma of procedure. Bleeding
-Within 1-2 days: epithelialisation of pocket wall
-1-2 weeks: epithelial re-attachment commences at the base of the pocket, new gingival sulcus forms & gingival recession as a result of inflammation (as inflammation resolves tissues shrink)
-3-6 weeks: formation of functionally-orientated collagen replacing granulation tissue, continued reduction in probing depths
-Over several months: continued maturation of connective tissue, possible bone infill in infra-bony defects

Question 51

What adjunctive treatments are available

Answer 51

Local antimicrobials: mouthwash, toothpaste, periochip (chip containing 2.5mg CHX effective for 7-10 days)
Systemic: antibiotics (rare), host-response modulators

Question 52

What is a periochip. how long it lasts

Answer 52

-used as an adjunct to RSD in moderate-severe periodontal sites
-used in patient who has responded well to RSI/ good OH but has a small number of persistent pockets that are failing to respond to treatment
-Releases CHX in the subginigval periodontal pocket at effective levels for 7-10 days
-Disintegrates within 7-10 days due to enzymatic degradation
-Does not stain teeth, no changes in taste
-antibacterial
-removes need for invasive perio surgery
-does not go into pockets < 5mm

Question 53

how chlorhexdine works

Answer 53

-antibacterial, antifungal and perhaps antiviral. Broad-spectrum.
-Bacteriostatic at low concentration, bactericidal at higher concentrations.
-Positively charged molecule destabilised the negatively charged bacterial cell wall causing lysis. Disrupts phospholipid membrne and contents leak out
-Substantivity so sticks to surfaces so prolonged action. Should be used at different time to tooth brushing. Check whether known allergy

Question 54

reasons for using antibiotics as an adjunct for perio therapy. And arguments against

Answer 54

• Bacteria initiate disease, but damage done mainly by host response
• Outcomes of RSD are not always predictable
• Recolonisation occurs
• Bacteria may persist in isolated anatomical niches. >500 species.
  -Antibiotics may reinforce traditional therapy by killing persisting microorganisms. Antibiotics only used in adjunct to therapy and not in isolation

Arguments against using antibiotics:
* Bacterial resistance
* Dental plaque is a biofilm. antibiotics useless against undisturbed biofilm
- Are they of any benefit in periodontitis?
* It all comes down to risk/benefit for the individual & society
* Only a small number strongly associated with disease so antimicrobial could unnecessarily kill microbes in the body.

Question 55

3 mechanisms for gene transfer for antibacterial resistance

Answer 55

-Transformation: uptake of free DNA in the environment (from dead bacterium)
-Transduction: transferred between bacteria via a virus
-Conjugation: direct contact

Question 56

antibiotic for treating acute periodontal abscess

Answer 56

amoxicillin 500mg 3 times per day for 7 days
then metranidazole
then clindamycin

Question 57

How doxycycline can be used to treat chronic perio disease

Answer 57

20mg doxycycline 2Xdaily for 3 months to modulate host response by decreasing MMP production and therefore collegenase activity so less tissue breakdown

Question 58

when to be taking X-ray for perio patients

Answer 58

Only take x-rays if you think sites are worsening, depth increasing by over 1mm. In rapid progressing perio re-take them in a couple of years.

Question 59

Issues with record keeping and common allegations related to perio disease

Answer 59

-failing to diagnose
-patient unaware of disease severity
-no evidence of perio monitoring or risk assessment
-no or poor treatment carried out
-no management of risk factors
-no referral made or offered when appropriate to do so
That is why it is essential to keep record of all examination, history, consent, perio assessment, discussions (risks/ benefits, options), treatments, follow-up

Question 60

Reasons for periodontal surgery (types of surgery)

Answer 60

-improve access for RSI
-improve access for guided tissue regeneration,
-excision of gingival hyperplasia (gingivectomy),
-correction of gingival recession (involves tissue graft),
-access subgingival caries
-increase supragingival tissues for restorative procedures
-crown lengthening
-furcation surgery

Question 61

Patient indications and contraindications for perio surgery. what must plaque score not be above

Answer 61

optimized OH, plaque score < 20%, non-surgical management first (OHI, RSI, review), motivated, not immunocompromised, non-smoker, reasonable prognosis of dentition.

Question 62

Difference between a free gingival graft and connective tissue graft for gingival recession surgery

Answer 62

-free gingival graft creates more keratinized tissue and deepens the sulcus. Split thickness flap raise, removal of overlying epithelium, leaving connective tissue/ periosteum bed, dissection of free gingival graft from hard palate, free gingival graft, sutures
- a connective tissue graft thickens tissue, achieving root coverage. Requires adequate sulcus depth. 3 sides split thickness flap leaving a periosteum and connective tissue bed. Subepithelial dissection of connective tissue graft. Insert of graft. Suture

Question 63

What is guided tissue regeneration. Name 3 types of biomaterial used for guided tissue regeneration

Answer 63

-Regeneration of lost periodontium in localized vertical defects. Allows direct vision for placement of stable biomaterial into well-constrainted defect. Barrier membranes include:
1. Biogide- prevents ingrowth of epithelium. Osteoblasts populate the wound, producing new bone, cementum and PDL for more stability.
2. Embogain – an enamel matrix derivative to stimulate cementoblasts.
3. Bio-Oss - provides a scaffold for osteoblasts to be layed down around

Question 64

Reasons for crown lengthening surgery

Answer 64

-to access subginigval caries, increase surface area for restoration, improve aesthetics for an uneven gingival contour (gummy smile)
-if restoration encroaches into biologic width (epithelial attachment) inflammation occurs. So must keep restoration 3mm clear of alveolar crest so may required crown lengthening
Raise flap, remove bone (3mm from proposed new restoration margins)

Question 65

Reasons for furcation surgery. Why it is not commonly done

Answer 65

improves patient’s ability to maintain OH around lower molar furcation defects
-BUT not commonly done due to the risk of sensitivity or loss of vitality as it requires loss of tissue to achieve this

Question 66

What is done at the 3 month perio review

Answer 66

-reviewing response to treatment
-periodontal revaluation and re-assessment: post-op PPDs (discuss implications with patient, highlight sites that require further treatment), bleeding index, mobility, suppuration, furcation lesions, recession. Comment if perio condition is stabilizing
-review OHI and patient motivation: current OH and gingival health, plaque score, further advice, re-assess motivation and compliance, re-asses risk factors
-decision making regarding further treatment: discuss with patient. Document next phase of treatment plan – further PMPR. Adjunctive treatment (mouthwash if poor dexterity), potential referral, supportive periodontal therapy, recall interval defined
-supra or subgingival instrumentation. Record instruments used, sites, if LA, post op advice
-perio indices should be completed on at least an annual basis to allow disease stabilisation to be monitored

Question 67

Observations that indicate perio treatment success and treatment failure

Answer 67

-Success= reduced pocket depths, BOP, inflammation, recession due to reduced swelling, reduced plaque
-Failure= poor plaque control, persistence of inflammation, ongoing BOP, erythema and swelling, persistent deep pockets or increasing depths, increasing mobility, suppuration

Question 68

cons of hand scalers and ultrasonic scaler

Answer 68

-hand scalers: remove more cementum than ultrasonic
-ultrasonic- sensitivity issues

Question 69

How ultrasonics work. difference between cavitron and peizon

Answer 69

ultrasonic instruments convert electrical to mechanical energy. electrical current creates alternating magnetic field which causes expansions. contractions which results in vibration of tip
-cavitorn: all sides of tip are active
-piezon: only the lateral surfaces of the tip are active

Question 70

how to manage chronic erythematous candida

Answer 70

-denture induced
-mechanically clean dentures thoroughly & soak them in chlorhexidine mouthwash or sodium hypochlorite for 15 mins twice daily. Leave dentures out as often as possible. Denture replacement or adjustment
-antifungal therapy if persists

Question 71

Management of chronic hyper plastic candida

Answer 71

antifungal treatment, advised to stop smoking
- Could develop into oral cancer. It is a premalignant condition.-Would usually refer patient to oral surgery department to take a biopsy.